Provider Demographics
NPI:1962028514
Name:MATHEW, CHRISTOPHER THOMAS (DMD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:THOMAS
Last Name:MATHEW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8975 W WARM SPRINGS RD APT 2104
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2898
Mailing Address - Country:US
Mailing Address - Phone:910-261-0643
Mailing Address - Fax:
Practice Address - Street 1:4744 BRYANT IRVIN RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3646
Practice Address - Country:US
Practice Address - Phone:817-786-0837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36215122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist